The purpose of this review is to examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer (EGC). Endoscopic mucosal resection (EMR) of EGC, with ...negligible risk of lymph node metastasis, is a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. EMR is a minimally invasive technique which is safe, convenient, and efficacious; however, it is insufficient when treating larger lesions. The evidence suggests that difficulties with the correct assessment of depth of tumor invasion lead to an increase in local recurrence with standard EMR when lesions are larger than 15 mm. A major factor contributing to this increase in local recurrence relates to lesions being excised piecemeal due to the technical limitations of standard EMR. A new development in endoscopic techniques is to dissect directly along the submucosal layer -- a procedure called endoscopic submucosal dissection (ESD). This allows the en-bloc resection of larger lesions. ESD is not necessarily limited by lesion size and it is predicted to replace conventional surgery in dealing with certain stages of ECG. However, it still has a higher complication rate when compared to standard EMR, and it requires high levels of endoscopic skill and experience. Endoscopic techniques, indications, pathological assessment, and methods of endoscopic resection of EGC need to be established for carrying out appropriate treatment and for the collation of long-term outcome data.
Gastrectomy with lymph node dissection has provided an excellent therapeutic outcome for patients with early gastric cancer, with a 5-year survival rate of 96%. The prevalence of lymph node ...metastasis of intramucosal- and submucosal-invading cancer was reported as approximately 3% and 20%, respectively, which means surgery may have been excessive for many patients with these diseases. The endoscopic distinction between mucosal and submucosal invasion is made correctly in only approximately 80% of tumors. However, this means that the pretreatment diagnosis is incorrect for 20% of those tumors otherwise identified as candidates for local treatment. Furthermore, the evaluation of lymphatic-vascular involvement associated with lymph node metastasis is available only through accurate histologic examination. It is essential to evaluate accurately the endoscopically resected specimen and then decide whether or not an additional surgical procedure is warranted. There are several techniques for endoscopic mucosal resection. It is difficult to correctly assess the depth of tumor invasion from resected materials by conventional endoscopic procedures in lesions larger than 15 mm. This is because such lesions often are resected piecemeal because of the size limitation of a resectable specimen. A new endoscopic procedure, endoscopic submucosal dissection, using an insulation-tipped needle knife specifically designed at the National Cancer Center Hospital, Japan, is superior to other endoscopic methods in the treatment of early gastric cancer, and provides an en bloc specimen. En bloc resections allow precise histologic staging and have the potential to prevent recurrent disease.
Japanese guidelines for gastric cancer treatment were first published in 2001 for the purpose of showing the appropriate indication for each treatment method, thereby reducing differences in the ...therapeutic approach among institutions, and so on. With the accumulation of evidence and the development and prevalence of endoscopic submucosal dissection (ESD), the criteria for the indication and curability of endoscopic resection (ER) for early gastric cancer (EGC) have expanded. However, several problems still remain. Although a risk‐scoring system (eCura system) for predicting lymph node metastasis (LNM) may help treatment decision in patients who do not meet the curative criteria for ER of EGC, which is referred to as eCura C‐2 in the latest guidelines, additional gastrectomy with lymphadenectomy may be excessive for many patients, even those at high risk for LNM. Less‐invasive function‐preserving surgery, such as non‐exposed endoscopic wall‐inversion surgery with laparoscopic sentinel node sampling, may overcome this problem. In addition, further less‐invasive treatment, such as ER with chemotherapy, should be established for patients who prefer not to undergo additional gastrectomy.
(
) antimicrobial resistance is an urgent, global issue. In 2017, the World Health Organization designated clarithromycin-resistant
as a high priority bacterium for antibiotic research and ...development. In addition to clarithromycin, resistance to metronidazole and fluoroquinolones has also increased worldwide. Recent international guidelines for management of
infection recommend bismuth or non-bismuth quadruple therapy for 14 d as a first-line treatment for
in areas of high clarithromycin and/or metronidazole resistance. Although these treatment regimens provide acceptable
eradication rates, the regimens used should not contribute to future resistance of
to antimicrobials. Moreover, these regimens can promote resistance, due to prolonged therapy with multiple antibiotics. A new strategy that can eradicate
as well as reduce the antibiotics used is required to prevent future antimicrobial resistance in
. Dual-therapy with vonoprazan and amoxicillin could be a breakthrough for
eradication in an era of growing antimicrobial resistance. This regimen may provide a satisfactory eradication rate of
and also minimize antimicrobial resistance due to single antibiotic use and the strong inhibitory effect of vonoprazan on gastric acid secretion.
Gastric adenocarcinoma carries a poor prognosis, in part due to the late stage of diagnosis. Risk factors include
infection, family history of gastric cancer-in particular, hereditary diffuse gastric ...cancer and pernicious anaemia. The stages in the progression to cancer include chronic gastritis, gastric atrophy (GA), gastric intestinal metaplasia (GIM) and dysplasia. The key to early detection of cancer and improved survival is to non-invasively identify those at risk before endoscopy. However, although biomarkers may help in the detection of patients with chronic atrophic gastritis, there is insufficient evidence to support their use for population screening. High-quality endoscopy with full mucosal visualisation is an important part of improving early detection. Image-enhanced endoscopy combined with biopsy sampling for histopathology is the best approach to detect and accurately risk-stratify GA and GIM. Biopsies following the Sydney protocol from the antrum, incisura, lesser and greater curvature allow both diagnostic confirmation and risk stratification for progression to cancer. Ideally biopsies should be directed to areas of GA or GIM visualised by high-quality endoscopy. There is insufficient evidence to support screening in a low-risk population (undergoing routine diagnostic oesophagogastroduodenoscopy) such as the UK, but endoscopic surveillance every 3 years should be offered to patients with extensive GA or GIM. Endoscopic mucosal resection or endoscopic submucosal dissection of visible gastric dysplasia and early cancer has been shown to be efficacious with a high success rate and low rate of recurrence, providing that specific quality criteria are met.
The purpose of this review was to examine a remarkable technical advance regarding the indications for and the technique of endoscopic resection of early gastric cancer. Endoscopic mucosal resection ...(EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan, probably owing to the high incidence of gastric cancer in Japan and the fact that more than half of Japanese gastric cancer cases are diagnosed at an early stage. Very recently, several EMR techniques have become increasingly accepted and regularly used in Western countries. Although these minimally invasive techniques are safe, convenient, and efficacious, they are unsuitable for large lesions in particular. Difficulty in correctly assessing the depth of tumor invasion and an increase in local recurrence when standard EMR procedures are used have been reported in cases of large lesions, because such lesions are often resected piecemeal owing to the technical limitations of standard EMR. A new development in therapeutic endoscopy, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa, and large lesions can be resected en bloc. ESD is not limited by resection size and is expected to replace surgical resection. However, it is still associated with a higher incidence of complications than standard EMR procedures and requires a high level of endoscopic skill. The endoscopic indications, techniques, and management of complications of ESD for early gastric cancer for properly carrying out established therapeutic endoscopy are described.
Curability is associated with resection width and depth in polypectomy. We evaluated the resection width and depth achieved with hot snare polypectomy (HSP) and cold snare polypectomy (CSP) for small ...colorectal polyps.
In this single-center, prospective, randomized controlled study, patients with rectal or rectosigmoid polyps ≤10 mm in diameter were treated with HSP or CSP. Resection width was evaluated as mucosal defect size, measured immediately postprocedure and 1 day later. Resection depth was histologically evaluated using obtained specimens.
Fifty-two patients were enrolled. Mean lesion size was 5.6 mm with HSP (n = 27) and 5.8 mm with CSP (n = 25). Mean mucosal defect diameter immediately after HSP and CSP was 5.1 mm and 7.5 mm, respectively (P < .001). The diameter 1 day after the procedure increased by 29% (95% confidence interval CI, 17%-41%) with HSP and decreased by 25% (95% CI, 18%-32%) with CSP (P < .001). Muscularis mucosa was obtained similarly with HSP and CSP (96% 95% CI, 82%-99% vs 92% 95% CI, 75%-98%; P = .603). Submucosal tissue was obtained significantly more frequently with HSP than with CSP (81% 95% CI, 63%-92% vs 24% 95% CI, 11%-43%; P < .001).
The resection width immediately after CSP was larger than that after HSP but was significantly smaller at day 1 after resection. Although the resection depth after CSP was more superficial, muscularis mucosa was obtained in most specimens. Thus, CSP has sufficient resection width and depth to enable complete polyp resection and potentially has a superior safety profile than HSP.
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To examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer.
Endoscopic mucosal resection of early gastric cancer with no risk of lymph node ...metastasis has been a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. Though this minimally invasive technique is a safe, convenient and efficacious method, it is insufficient for larger lesions. Difficulties in correctly assessing the depth of tumour invasion and increases in local recurrence by standard endoscopic mucosal resection have been reported in lesions larger than 15 mm. This is because such lesions are often resected piecemeal due to the technical limitation of standard endoscopic mucosal resection. New developments in endoscopic resection techniques to dissect the submucosa directly, called endoscopic submucosal dissection, allows resections of larger lesions en bloc. There are no limitations in resection size in endoscopic submucosal dissection, which is expected to replace surgery. This technique, however, still has higher complications rates than standard endoscopic mucosal resection and requires highly skilled endoscopists.
The techniques, indications, and pathological assessment methods of endoscopic resection of early gastric cancer are described so that proper treatment guidelines can be established and long-term outcome data can be assessed.
Current evidence shows that individuals with gastric dysplasia, severe and extensive gastric atrophy, extensive gastric intestinal metaplasia and the incomplete subtype of intestinal metaplasia are ...at high risk for gastric cancer (GC) development. There are several approaches to identifying these subjects, including noninvasive methods, esophagogastroduodenoscopy and histology. The main approach in Western countries is histology-based while that in Eastern countries with a high prevalence of GC is endoscopy-based. Regarding asymptomatic individuals, the key issues in selecting applicable approaches are the ability to reduce GC mortality and the cost-effectiveness of the approach. At present, population-based screening programs have only been applied in a few Asian countries with a high risk of GC. Pre-endoscopic risk assessment based on demographic and clinical features, such as ethnicity, age, gender, smoking and
status, is helpful for identifying subjects with high pre-test probability for a possibly cost-effective approach, especially in intermediate- and low-risk countries. Regarding symptomatic patients with indications for esophagogastroduodenoscopy, the importance of opportunistic screening should be emphasized. The combination of endoscopic and histological approaches should always be considered as endoscopy provides a real-time assessment of the patient's risk level. In addition, imaging enhanced endoscopy (IEE) has been shown to facilitate targeted biopsies resulting in better correlation between endoscopic and histological findings. Currently, the use of IEE is recommended for endoscopic examinations, and the Operative Link for Gastric Intestinal Metaplasia or Operative Link on Gastritis Assessment grading systems are recommended for histological examinations whenever available. However, resource limitations are an important barrier in many regions worldwide. Thus, for an approach to be applicable in real-life practice, it should be not only evidence-based but also resource-sensitive. In this review, we discuss the current understanding and approaches to identifying high-risk individuals from western and eastern perspectives, as well as the possibility of an integrated, resource-sensitive approach.
Background
Additional surgery for all patients with noncurative resection after endoscopic resection (ER) for early gastric cancer (EGC) may be excessive due to the relatively low rate of lymph node ...metastasis (LNM) in such patients. However, the prevalence and risk factors for LNM after noncurative ER have not been consistent across studies.
Methods
We performed a systematic review of electronic databases through August 10, 2018 to identify cohort studies with patients who underwent additional surgery after noncurative ER for EGC. The prevalence of LNM in such patients was extracted for all studies. Odds ratios (ORs) were combined using random-effects meta-analyses to assess the risk of LNM, when possible.
Results
We identified 24 studies comprising 3877 patients with 311 having LNM (pooled prevalence, 8.1%). The risk of LNM was significantly increased in lymphatic invasion (OR 95% confidence interval = 4.22 2.88–6.19), lymphovascular invasion (LVI) (4.17 2.90–5.99), vascular invasion (2.38 1.65–3.44), positive vertical margin (2.16 1.59–2.93), submucosal invasion depth of ≥ 500 μm (2.14 1.48–3.09), and tumor size > 30 mm (1.77 1.31–2.40). In contrast, there was no significant association between undifferentiated-type or ulceration (scar) and LNM. When studies were restricted to those that evaluated the adjusted OR, the risk of vascular invasion for LNM did not reach statistical significance.
Conclusions
Several pathological factors, most notably lymphatic invasion and LVI, were associated with LNM in patients with noncurative resection after ER for EGC. Lymphatic and vascular invasion should be assessed separately instead of LVI (PROSPERO CRD42018109996).
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